Welcome to Clinical Meeting

Dr. KANTA HALDER Resident (MD;Phase A),

General Pediatrics;BICH.

Particulars of the patient Name: Khadiza. Age: 1 month 23 days. Sex: Female. Address: Uttara, Dhaka. Date of Admission: 08.10.2016. Date of Examination: 09.10.2016.

Chief Complaints

Swelling of whole body for 7 days. Not growing well since birth.

History of present illness According to the statement of mother, her

child developed swelling of whole body for 7 days which first involved both feet and then gradually involved both legs and hands. Mother also complained that her child is not growing well in comparison to other peers of same age group since birth. She has no H/O fever, cough, respiratory distress or contact with TB patient.

Cont.. With these complaints they consulted a local

doctor who referred the child to Dhaka Shishu Hospital for further evaluation & better management.

History of Past illness She had H/O watery diarrhoea 20 days

back and was treated by a local doctor with some oral medication, but mother could not mention the names.

Birth History Mother, a 18 years old malnaurished lady,

was on irregular antenatal check up. Khadiza was delivered normally at 36 weeks

of gestation at a local clinic with low birth weight, as one of the twin, without any postnatal complication.

Feeding History No prelacteal feed was given to her. She was

on breast feeding up to 15 days of age which was inadequate in amount. Then breast feeding was stopped and formula feed was started with inappropriate dilution. Diluted formula milk was prepared with ½ tsf milk with ½ tsf sugar in 30 ml of water each time and given about 5 times a day.

Feeding History (cont..)• She received= (½ tsf milk + ½ tsf sugar) x 5 = (10 +10) x 5 = 100 kcal/day.• Expected calorie requirement= (4.5x100) kcal. = 450 kcal/day.• Expected calorie deficit= (450 – 100) kcal. = 350 kcal.• Existed calorie deficit= (170 – 100) kcal. = 70 kcal.

Developmental History She has no neck control till date. She can recognize mother’s lap.

Immunization History She is not yet immunized.

Family History She is the 1st issue of her non-consanguineous

parents. Her twin sister is suffering from similar type of illness.

Socio-economic History She belongs to a low socio-economic family.

Her both parents are garment workers. Their monthly income is around 8,000 taka. They live in a tin-shed house, use sanitary latrine and drink boiled water.

General Examination Appearance: Conscious, irritable. Anaemia: Moderate. Jaundice: Cyanosis: Clubbing: Absent Dehydration: Edema: Grade ++.

Cont..Hair: Normal.Eye: Normal, no eye change.Ear:Nose: NormalThroat:Skin: BCG mark absent. No other skin

manifestation.Lymphnode: Not palpable.

Cont..Vital Signs:

Pulse: 120/min.Respiratory Rate: 36/min.Temperature: 98°F.

Anthropometry:

Cont..

Weight: 1.7 kg. Lenght: 40 cm.WAZ: - 5.0 (severely underweight). LAZ: - 3.1 (severely stunted).WLZ: - 3.0 (moderately wasted). OFC:

Systemic Examination Alimentary System:

Mouth and Oral Cavity: Normal Abdomen: Inspection: Abdomen is mildly distended,

flanks are not full, umbillicus is centraly placed and inverted.

Palpation: • Liver is palpable, 1 cm from right costal

margin along right mid clavicular line which is non tender ,surface is smooth, regular border. Upper border of liver dullnes is present at right 5th intercoastal space.

• Spleen: Not palpable.• Fluid thill: Absent. Percussion: Shifting dullness absent. Auscultation: Bowel sound present.

Cont..

Cont.. Respiratory System: Inspection: Respiratory rate - 36/min. Palpation: Trachea is centrally placed.

Apex beat in left 4th ICS just lateral to MCL .

Chest expansibility: Normal. Vocal fremitus: Normal.

Percussion note: Normal. Auscultation: Breath sound is vesicular, no

added sound.

Cont..

Cardiovascular system: Normal.

Other Systemic examination: No abnormality.

Salient features Khadiza, 1 month 23 days old non immunized

infant, 1st issue of her parents, one of the twin, from poor socio-economic background, presented with generalized oedema for 7 days and failure to thrive since birth. She was born prematurely with low birth weight and had H/O a recent diarroheal episode along with H/O gross feeding mismanagement from her early life with existed calorie deficit of 70 kcal/day and expected calorie deficit of 350 kcal/day.

Salient features (cont..) She is ill looking, irritable, moderately pale,

normothermic, having grade II oedema. She is severely underweight, severely stunted and moderately wasted. There is hepatomegaly without ascites. Other systems reveal normal findings.

Provisional Diagnosis

Severe Acute malnutrition (oedematous).

InvestigationsComplete Blood Count :

• Hb: 8.2 gm/dl.• WBC: Total count: 12,500/mm3. Differential count:

o Neutrophil: 31%o Lymphocyte: 65%o Monocyte: 02%o Eosinophil: 02%o Basophil: 00%

Cont..

o RBC: Anisocytic anisochromic.o WBC: Mature with above

distribution.o Platelet: Adequate.

• Platelet: 296,000/mm3.• PBF:

Cont.. RBS: 4.7 mmol/L. S. Electrolytes:

Na+: 136.4 mmol/L.K+: 4.4 mmol/L.

Cl-: 102.4 mmol/L. S. albumin: 13.6 gm/L. Blood C/S: Negative. Urine R/E: Normal. Chest X-ray: Normal.

Final Diagnosis

Severe Acute malnutrition (oedematous).

Management Initial management (Stabilization phase): Prevention of hypothermia: by proper

clothing. Prevention of hypoglycemia: 50 ml bolus of

10% glucose by NG tube. Feeding:• Restablishment of breast feeding.• F-75 (without cereal) through NG tube: 15 ml 2 hrly (12 feed).

Management (cont..) Antibiotics:• Inj. Ceftriaxone 150 mg once daily. Cap Vit-A: 50,000 IU P/O single dose. Tab Folic acid: 5mg stat and 1/4th tab daily. Syp Zinc: 2 mg/kg/day ( 1/3 tsf daily) Multivitamin drop without iron.

Management (cont..) Mother’s diet: High calorie & high protein

diet.• Rice with fish/meat.• 1 egg• 1 banaba.• 2 glasses of milk.• 8 – 10 glasses of water.

Management (cont..) Plan for Rehabilitation phase: Intensive feeding with breast milk. If not

possible, then diluted F-100. Syp. Iron 3mg/kg/day for 3month. Provide stimulation: Play and loving care. Preparation for discharge. Follow up.

Thank You